- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,524.65 / $3,278.00 / $5,743.00
| Facility | | $1,524.65 | $3,278.00 | $5,743.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.29 / $612.50 / $4,189.43
| Professional | | $368.29 | $612.50 | $4,189.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.97 / $447.13 / $651.60
| Facility | | $340.97 | $447.13 | $651.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $658.00 / $4,445.00 / $4,912.00
| Facility | | $658.00 | $4,445.00 | $4,912.00 |